Healthcare Provider Details

I. General information

NPI: 1619641016
Provider Name (Legal Business Name): AMY JOHANNA GRAHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2021
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 BORDEAUX ST
CHADRON NE
69337-2617
US

IV. Provider business mailing address

910 BORDEAUX STREET
CHADRON NE
69337-2617
US

V. Phone/Fax

Practice location:
  • Phone: 308-327-2026
  • Fax:
Mailing address:
  • Phone: 308-856-9707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12717
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3637
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: